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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434402043
Report Date: 05/17/2023
Date Signed: 05/17/2023 11:58:05 AM

Document Has Been Signed on 05/17/2023 11:58 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:SIVIRA, CARMENFACILITY NUMBER:
434402043
ADMINISTRATOR:SIVIRA, CARMENFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 749-8302
CITY:SUNNYVALESTATE: CAZIP CODE:
94086
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 7DATE:
05/17/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:44 AM
MET WITH:Carmen Sivira
TIME COMPLETED:
12:15 PM
NARRATIVE
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LPA Teodoro Trujillo met with licensee Carmen Sivira for a case management inspection regarding the deficiencies cited on 05/09/2023. LPA observed seven (7)children in care: two infants, five preschool age, one infant arrived during site visit.

LPA provided licensee the Letter of Deficiency Citations Cleared for citations from 05/09/23 visit, section 102417(b), 1596.866(b)(1), 102417(g)(8) and 102425(c) today. LPA observed LIC 9224 Acknowledgement of Receipt of Licensing Report with parents' signatures in all children's files.

There are three adults living in the home, the licensee, her husband and her father. A review of staff records on 05/17/2023 indicates that not all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Licensee father has not received criminal record and child abuse index clearances or exemptions, father was present on previous site visit on 05/09/2023 and did his Live Scan Service on 05/15/2023. Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.
Type A deficiencies were cited during today's visit. LPA Teodoro Trujillo informed licensee Carmen Sivira that this report dated 05/17/2023 document(s) 1 (one) Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.
Also, LPA Teodoro Trujillo informed the licensee Carmen Sivira to provide a copy of this licensing report dated 05/17/2023 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

Licensee was informed that failure to correct the deficiencies by the specified Plan of Correction Due Date will result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made.
Exit interview conducted and report was reviewed in Spanish with the licensee, Carmen Sivira. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/17/2023 11:58 AM - It Cannot Be Edited


Created By: Teodoro Trujillo On 05/17/2023 at 11:02 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: SIVIRA, CARMEN
FACILITY NUMBER: 434402043

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/18/2023
Section Cited
CCR
102370(d)(1

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(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or
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Licensee will submit proof of background clearance for her father Jose to the San Jose Regional Office. Jose shall not be present in the child care home until he obtains a California clearance or a criminal record exemption as required.
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Based on observation, interview and record review, the licensee did not comply with the section cited above in, licensee father does not have criminal background clearance, which poses an immediate health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Mary Segura
LICENSING EVALUATOR NAME:Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2023


LIC809 (FAS) - (06/04)
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